3. CELEBRITY TRANSPLANTS AND SQUEAKY WHEELS
How is it that famous people who need transplants often get them? And how is it that people who embark on flashy publicity campaigns often get them as well?
Consider the case of Pennsylvania's former governor Robert Casey. Casey's heart and liver deteriorated in the summer of 1993, he was told he needed a double transplant, and he got one the next day. Is it fair to assume that, as governor of the state, Casey may have been given priority over others who had been waiting longer for those two organs or that he may have known better than most how to "work the system?"
Or take the case of Mickey Mantle, the New York Yankee's center fielder who received a liver transplant in 1995. Mantle had liver cancer, hepatitis, and cirrhosis of the liver. The latter was attributed to his many years as an alcoholic. When Mantle's medical condition turned "critical," his name was put on the waiting list for a liver in Dallas, and he was admitted to the hospital. Mantle's name stayed on the waiting list just 48 hours before his diseased liver was removed and he received a new liver. (In 1995, the median waiting period for others on the waiting list for a liver in Texas was 183 days, according to a 1996 report.) Mantle's tumor was so aggressive that it quickly took over the new liver just as it had done with his original liver, and he died about two months after the transplant.
Or, finally, what about the story of the California couple who appeared on the Phil Donahue show to plea for a heart for their dying baby son. Part way through the show, a call came from a spokesperson from a hospital in Michigan: "We are donating a heart to the baby in Loma Linda, California." After tears and embraces and a disclaimer that the donation had not been arranged ahead of time, the couple left the show to head back to California, where subsequently the heart transplant took place. On closer inspection, it turned out that a baby in Kentucky was at the top of the transplant list and should have received the Michigan heart.
The need for organs is great, but the supply is small. By mid 1999, some 63,000 people in the United States were awaiting organs, but most would not get them. How should the choice be made as to who gets available organs? Is it really fair that celebrities?whether famous, powerful, or media-savvy?seem to be able to "jump the queue?"
- New York Times, 1995, August 15, C1, C3.
- Washington Post Health, 1993, 9(25): 8-9.
- New York Times, 1986, June 15, A1, A16.
- Washington Post, 1996, December 9, A1, A8.
- Richard Selzer, Liver, in Mortal Lessons, Simon and Schuster, 1974.
- Time, 1989, December 11, 134(24):96.
- New York Times, 1994, July 8, B7.
Students should understand the following:
- How the liver functions
- What the liver does
- What conditions can lead to liver failure
- Why the liver regenerates while other organs do not
- The surgery, procedures, and risks involved in liver transplantation
- The life-long restrictions placed on the recipient post transplantation
- The procurement of organs (Procurement Act of 1984) and the laws involved
- The UNOS registry system
- How donor suitability is determined
- Current success rates for various transplants
- How organs are preserved until they are transplanted
- Transplantation does not always benefit recipients?sometimes it just advances knowledge
- The power of the media
Suggested questions for discussion
- Both Casey and Mantle rose legitimately to the tops of their waiting lists. Is it likely that the doctors manipulated their situations so that each could qualify quickly for a transplant?
- Is it possible that the transplant teams chose Casey and Mantle as recipients in order to gain media recognition for themselves? On the other hand, is it possible that the transplant team members took the opportunity to gain media attention and through that were able to highlight the need for more organ donations?
- The imbalance between organ supply and demand remains enormous, with demand continuing to outpace supply. What are the obstacles to securing organs from both living and non-living donors?
- Often, when transplanted organs fail, the donor is given a second organ. Do you think this is a fair policy or should someone else, who has never received a transplant, be given a chance?
- To what degree, if any, should lifestyle be a consideration for candidacy for organ recipients?
- What demands can be made of organ recipients in terms of their future behaviors?such as prohibitions against smoking and drinking? Would this violate their rights?
- End-stage liver disease and end-stage heart disease differ from end-stage kidney disease. In liver and heart disease, patients will die without a transplant, whereas patients with kidney failure can stay alive for years with dialysis. What differences would you expect in the attitudes and outlooks of patients with end-stage liver or heart disease from those with kidney disease?
- What fears are common in people who need organs? (Fear of not being accepted on the waiting list, dying while waiting, dying during surgery, organ rejection, low quality of life post transplant, reacting to immunosuppressive drugs.)
Topics for discussion/written assessment
- Patients receive "points" that determine who is at the top of the organ waiting list. For livers, patients get points when their blood group matches that of the organ donor. Points are then assigned for medical urgency. Patients in intensive care receive more points than those still at home. Finally, points are awarded for those who have been waiting a long time and for those who live near the donor. How can this type of system be manipulated? What other factors would be important in determining who gets an organ? Some options to consider are these: "most likely to succeed," that is, the one most likely to benefit and get long use from the organ; the most needy from the medical standpoint (the sickest person); the healthiest person on the list (the patient with the best chance of recovery after transplantation); the most valuable patient (how would "value" be determined?); those who can pay; choose recipients by lottery; first-come, first-served (what is the impact of type of health care on first-come, first-served policies?); decisions by a committee (who should be on the committee?).
- What are the drawbacks to letting doctors choose who gets organs? (Consider that doctors may be prejudiced toward patients they know or like.) Should children and adults compete on the same waiting list? (Consider the following factors: children are "works in progress," some adults have?through smoking, drinking and diet?damaged their own organs, some adults may be especially valuable to their families and society.)
- A child who needs a liver can sometimes be given a piece of one parent?s liver. In this situation, as in the case of some kidney transplants, living donors are involved. The procedure has worked remarkably well. The liver regenerates in the adult donor to the original size. In the child, the new liver section expands into a normal liver that continues to grow as the child grows. What moral and legal obligations, if any, do parents of children with liver failure have to investigate their suitability as donors? What are the risks and benefits to the donor?
- When a donor designates a specific recipient, the waiting list becomes irrelevant. Some people argue that designated donations are unfair and should not be accepted. Others argue that the donor or the donor's family member has the right to designate a recipient and that this actually increases organ donation. How would you evaluate and balance these positions? Are there drawbacks, besides subversion of the waiting list, that you might foresee from designated donation?
- A young Maryland boy, Daniel Canal, received 12 new organs in a single year: three livers, three pancreases, three small intestines, and three stomachs. The first time the four organs were transplanted, the stomach shut down. The second time, his body reacted against all the organs and tried to reject them. The third transplant appears to have been successful. How would you justify the decision to give one person 12 organs rather than giving 12 people one organ each? Did Daniel's need for four organs arise because he was on the waiting list for a long time before he qualified for the transplants?
- In 1999, the Clinton Administration pushed for a change in organ distribution for livers, such that an available liver would be given to the sickest person nationally rather than to the sickest person in the donor?s region. They argued that this approach is fairer and is feasible now that techniques are available for preserving livers longer. What are the pros and cons of a national, rather than a regional, system for distributing organs?
- Many "human" factors affect donation. Some argue that people prefer to donate if they know the doctor or the recipient. They argue that, if distribution is done nationwide rather than locally, donations will decrease. How do you assess the importance of human factors in the decisions that individuals make about becoming donors?
- Mickey Mantle lived only a few months after he received a transplant. But the publicity around his transplant led to increased donations, more awareness of the organ shortage, and more attention to signing donor cards. Compare the personal benefit Mantle received to these societal benefits. Consider also how another person might have benefitted from the organ that Mantle received. Did the doctors make the right choice?
- The people who appeared on the Phil Donahue show were not married, and their baby was first denied an opportunity to be on a transplant list at Loma Linda because of this. Is it just to refuse a heart to a baby based on the marital status of the parents? What about people who are on public assistance?
- How are patients chosen for available organs? What factors go into the decision?
- How do societal "beliefs" about what is right affect outcomes in organ transplantation decisions?
Topics for teacher preparation
- The physiological function of the liver
- End-stage liver disease and liver failure
- The surgery, procedures, and quality of life for recipients of liver transplants
- Directed donation, required request, opt-in system, opt-out system
- Definition of death
- UNOS registry assignment of patient status
- Organ Procurement Act of 1984